The biggest mistake of your life?
"This is the first job I've held where an 'off' day and a relatively minor mistake could potentially result in a prosecution."
The words of an iPM listener about her job as a pharmacist.
She emailed us, horrifed to hear that a fellow pharmacist in Windsor was prosecuted following an error in dispensing drugs. Our listener writes:
"Since this hit the news I've spoken with pharmacy colleagues and thought 'there but for the grace of God...'. At a pharmacy education night a few years ago we were asked to share errors we'd made to learn from each other - we were honest and supportive but most of us could have been prosecuted for what was essentially an uncharacteristic error.
Outside the pharmacy world I'm not sure that many people realise that an error in our profession could result in a criminal record."
In fact, she hadn't realised that she could be prosecuted, until this case arose and it's changed the way she sees her work.
Are you a pharmacist with similar concerns? Have you been dispensed the wrong drugs by a pharmacist? Or perhaps you work in a job where an 'off' day could have serious repercussions? Comment below or email us.
UPDATE 8 Jun: Thanks to everyone who contacted us, much appreciated and we're continuing to follow up on your comments.
We brought together the pharmacist who contacted us (above) and another iPM listener, Rose-Mary Gower. Rose-Mary's husband received double his usual dose of an epilepsy drug, but she was surprised by the response of her pharmacist when she pointed it out.
Listen to the discussion as it was broadcast on Saturdays programme (9. 54 mins)
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Comments
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I think that in no other area of medicine would some one be prosecuted and convicted of manslaughter for 'an error' - I feel that she was not negligent but certainly overworked - I quit retail (community) pharmacy and one of the reasons was the expectation of the corporate giants who have taken over our 'local' pharmacies to work with no lunch or breaks for up to 11 hours a day, every minute of which had a 'life or death' decision as documented in this case. Please take an objective view... sorry but this is just an example of the law being taken by the letter and a good, caring pharmacist having to end her career - one which she studied many years to achieve.
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I am a pharmacist. Perhaps my view is slightly different to that expressed by my colleagues. I have no problem with pharmacists being criminally liable for any practice mistakes they make, as long as all other professionals are treated the same way. This would produce a very sudden and severe brake to the improvement of service quality in all professions,after all we learn from our mistakes not from the things we do correctly. All pharmacists are trained in Clinical Governance, as a mechanism for professional improvement and the basis of this is transparency, which will not happen in an evironment of fear of prosecution. All pharmacists are subject to professional censure by our professional body if we are found to be lacking professionally and ultimately may lose our livelihood. If it is shown that a pharmacist has acted with professional negligence then I believe that the a criminal prosecution should be the norm and a custodial sentence on guilty verdicts should be the expectation, my colleagues may disagree with me. It is a matter of some regret that our professional body has again been shown to be merely reactive and as a result a perfectly good pharmacist who had a terrible lapse of concentration has been one of the casualties.
The pharmacist in question was complimented by the judge at her trial for her openness, typical of the profession in my opinion.
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I agree that pharmacists are one profession when a genuine mistake can have serious consequences, I work in another. Doctors too are subject to increasing regulation and pressures at work to try to avoid mistakes happening - salutary in its aims but in reality makes working in the health service feel like we are constantly under scrutiny and have to 'prove' that we are safe at what we do.
Regarding the pharmacy issue I have seen it from both sides, as a doctor working in the NHS for several years I rely on pharmacists and I see the pressure and the workload they are under. I am also a customer of community pharmacies and can immediately remember 2 separate occasions when I was given a quantity of drugs which did not match what was on the doctor's prescription, despite being checked by two people. This was not a problem to me but had it happened to someone else it could have had serious consequences. The only way through it I can see is to train up more pharmacists and give them better working conditions. Sounds like common sense to me but people obviously don't see it that way when footballers and bankers earn the big money and people who actually do a vital job struggle to get by.
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Sadly this story is true. In what other profession is a single error a criminal offence? As a pharmacist with 25 years experience I have dispensed tens of thousands of prescriptions and inevitably I have made a small number of dispensing errors. Each of these is - if the strict letter of the law is applied - a criminal offence. Equally I have seen many hundreds of inadvertent prescribing errors which I have corrected but this would not mitigate against my own failings. The NHS is keen for all healthcare staff to be open about their errors or omissions, to be a learning organisation and to avoid a "blame" culture. I know of no experienced pharmacist who has not made a dispensing error. We are all "criminals". Crminalisation of dispensing errors is a ludicrous and draconian piece of legislation which should be amended or repealed as soon as possible.
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What's disappointing is that the company owning the pharmacy was not prosecuted. They should have a clear legal duty (ideally on each of the directors personally, as well as the company) to ensure that they have systems in place that will prevent all reasonably foreseeable prescribing mistakes from happening. Each prescription should be checked two or three times, by different people, making sure that the label, the contents and the prescription all agree exactly. Regular "ringers" should be put into the system to test that these checks are being applied rigourously and any "near misses" should be recorded and followed-up.
Yes, it will cost a little more, but it will probably save more lives per pound spent than many high-tech drugs or medical procedures.
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I am a pharmacist working in a hospital. I am a specialist chemotherapy pharmacist and frequently feel the pressure of 'one mistake...'; I feel I am now under far greater pressure than when I was working in the dispensary and on the wards as chemotherapy production is such a high risk area. Not only am I responsible for the effective and timely delivery of chemotherapy doses to the oncology suite, I am also responsible for the safety and well being of my colleagues who are working in close proximity with extremely hazardous drugs. Due to the cytotoxic nature of the drugs I deal with and the different treatment protocols depending on the cancer being treated, there is a far smaller margin for error.
Today I worked from 8.30 to 5.30 having only a twenty minute break -this was all I had time for. I was the only pharmacist in our production unit until 2pm when a colleague was freed up from other duties to assist me. I have been qualified less than two years. When I started in my current post eleven months ago, I couldn't beleive my luck at landing my 'dream job'; on Friday I handed in my notice. I have another job to go to, but am seriously disillusioned with the whole profession: this was not what I signed up for when I chose to be a pharmacist.
To add to the pressure, this week I am on call. I was handed the on call pager last Friday morning and will carry it until this coming Friday morning. This means seven nights of poor quality sleep (although I not regularly awoken, I might be -and therefore do not sleep), and seven evenings tee-total and on edge -waiting for the pager to go. When it does go, I have to answer in under five minutes and may have to drive back to the hospital if needed. I have written this in two attempts due to being paged whilst writing.
This is lengthier than intended, but I feel better having got this off my chest.
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For more resources regarding the recent legal case, the current campaigns being run by the Pharmacists Defence Association and the Royal Pharmaceutical Society and the on-line petition see the links below:-
http://www.the-pda.org/newsviews/nv_topical_news1.html?id=1670
http://www.pjonline.com/dispensing_error_decriminalisation_resources
http://www.chemistanddruggist.co.uk/news
http://www.gopetition.com/petitions/decriminalisation-of-dispensing-errors/signatures.html
http://www.the-pda.org/newsviews/nv_topical_news1.html?id=1650
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For a wider perspective related to pharmacy ownership here is the latest editorial from the Pharmaceutical Journal:-
http://www.pjonline.com/news/where_are_the_multiples
and a press release from the European Court of Justice judgement 19th May 2009 relating to the ownership of pharmacies:-
[Unsuitable/Broken URL removed by Moderator]
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I am a regular and frequent user of the chemist which is situated nnext to my local Supermarket. The chemist is owned and run by a chain known as Weldricks.
The service in the chemists is abysmal.
Although prescriptions are delivered there daily from the Medical Centre (100 yards away) I can guarantee that I have to go back there twice before the prescriptions can be collected.
Always, when you walk in, there are three or four people hiding behind the dispensary area talking about last night's television, who is getting married to whom and, whilst looking out of the shop window, "I wouldn't have worn red shoes with that skirt"
The range of excuses I have come across for not having prescriptions ready are as follows:-
1) I know we have had the prescription since 10.00am and it is now 1.00pm but the chemist needs to check this and he does not get back from lunch until 3.00pm.
2) I am sorry we have some of your requirements. Here is a note, please come back for the others.
3) We have none of these in stock. They will be here in three days time ( this was proposed when I was trying to collect medication for an Alzheimers patient.
Perhaps I have fallen into the trap of "instant gratification" where I can go into a shop 24/7 and buy what I want and am expecting this to be carried over to the precription service of the chemists?
I work part time and care for my wife when at home. I do not have the time to stand in the chemists waiting until anyone of five people (four assistants + one chemist) can be bothered to find out what my requirements are.
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Comment 5. contains a lot of white space and may mean other viewers won't scroll down to see lower posts.
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The pharmacist from Windsor has done more to help the profession than anyone else recently. The suspended prison sentence is a nonsense. No wonder the Pharmaceutical Society decided to take no further action. Their normal response to a single dispensing error is an admonition: that would have looked most odd against a prison sentence from the court! About time pharmacists got realistic.
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I too was shocked that a professional and caring pharmacist now has a criminal record because of one small error (and an error which had zero impact on the demise of the poor patient). She resigned immediately afterwards, but the supermarket that expected her to work illegally long shifts without breaks has not been prosecuted. I believe that an out of touch judge was pandering to a family who were baying for blood.
Pharmacists make 4 serious errors per 10000 prescriptions dispensed. This is too many and should be improved on, but it is still quite impressive. If only a study could be done to find out how many serious errors per 10000 prescriptions we prevent doctors from making - but unfortunately we wouldn't have the time to do this without distracting us from one of our very important functions.
I too handed in my notice recently because I felt that my employer's professionalism regarding operating a pharmacy was far below mine. And he is a GP.
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I am a community pharmacist of 14 years experience and the workload and pressure increases year on year As a profession we are taking on yet more roles with little or no more remuneration and work long days with few or no breaks. Whilst one is entitled to take a break, a pharmacy cannot function without a pharmacist and in most pharmacies it is not economically viable to employ 2 pharmacists everyday. When a break is taken and the pharmacy closes it often enrages customers (who expect a 24/7 service)these customers are, in turn unpleasant to other staff members. In addition on returning from the break the workload of prescriptions has piled up. As a business a pharmacy needs to keep its customers happy otherwise they go elsewhere hence it is very difficult to take a break. Moves are a foot to change the situation regarding how a dispensary runs in the pharmacists absence. This will i fear give the large chains carte blanche to reduce the number of pharmacists they employ further and deny the public pharmcay's unique selling point ie you can walk off the high street and ask for health advice without an appointment. I love my job but the pressures are starting to take their toll. We are all human and humans make mistakes. The challenge is to ensure that systems are in place to minimise the risk but the pressures we work under make errors more likely.
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i'm a senior hospital pharmacist. Certainly in the last few years great emphasis has been placed on "risk management"....trying to reduce risk to patients via various means (having second dispensing checks, SOPs- standard operating procedures to minimise variance in practice, clinical audit to improve processes, together whith an open culture of root cause analysis to learn from mistakes.)
That said i think its important to put this into perspective...with the best will in the world, the best systems in place, you can never completely avoid human error. Both in hospital and community pharmacy the shear volume of drug dispensing that takes place, the long hours worked, the stress involved of being bombarded simultaneously by questions & demands from patients, the telephone ringing and reems of prescriptions to be dispensed means that inevitably mistakes are occasionally made. the nature of our work means that, yes, it may be potentially fatal.
The judge said the sentence needed to be imposed to mark the gravity of the offence. This was not a criminal offence, it was a very unfortunate mistake. i can't remember the last time i heard about a medic receiving this kind of punishment (are we to compare her to shipman?!). it seems any professsional negligence for a medic is dealt with "in house" by the mass machinery of the GMC. This was a professional matter not a criminal one and should have been dealt with soley by the RPSGB.
if this sets a precedence, then there's about to be a lot of well educated inmates at her majesty's pleasure
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It is extreemly regretable that the Insurance company who should have protected the interests of the pharmacist in question chose to conduct a test case and lost, and as a result the overworked pharmacist has been forced to resign from the pharmaceutical register and her chosen and hard won career. The 5 year degree course is not easy to complete. I am nearing the end of a long career in Pharmacy and have watched the progressive emasculation of Pharmacists and the year on year increase in their workload. 25years ago a busy average pharmacist was expected to dispense around 2000 items a month today the average is around 6000 many regularly doing 10000 or more with a single Pharmacst in charge. Then the company was paid £2 per item today the payment is less than £1/item. At the governments insistence Pharmacy companies that want new contracts must open for 100 hours per week. This has led to longer shifts for some pharmacists and a chronic shortage of relief pharmacists. There is no requirement to provide a second pharmacist when workload is excessive. In October 2007 the Government removed so much money from the Pharmacy budget that it was able to balance the Primary care deficit in a single year but it left Pharmacy very near bankrupt. Most independant pharmacies have had to resort to some form of refinancing. The large companies have reduced staffing levels to such an extent that many should be declared unsafe places of work. This has added to the workload and lead to the 'mistake' of the Pharmacist concerned and will inevitably lead to many more.
Pharmacy needs access to funding to be able to produce the results that the Government wants, it cannot continue to do more and more for less and less. Nothing short of a complete independant cross party review will sort out the mess Pharmacy finds itself in!
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I think it is so sad. I am a community matron and have always enjoyed excellent working relationships with community pharmacists. Working with elderly, frail and terminally ill patients is stressful enough so having a pharmacist able to get drugs at short notice is so welcome. We all make mistakes. I have made mistakes but I am fortunate that my PCT encourages its staff to report errors and near misses so we can learn from them. I can tell you that discovering an error, reporting it and working to avoid it happening again is made so much easier if you know that you are not going to be treated like a criminal. I was congratulated for being so open by several senior mangers, something I was not expecting. My daughter works as a pharmacist and works long hours to provide a high quality service in an inreasing litigious NHS and it would be so sad to lose such enthusiam from someone at the start of her profession.
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I am also a hospital pharmacist.
Although this is a tragic case for all involved, the original mistake was a simple one, confusing two similar names at the end of a long, busy shift. Although the pharmacy profession makes every effort to avoid such regrettable errors, given the millions (literally) of prescriptions dispensed annually, it is inevitable in a system reliant on human beings that such mistakes will occur from time to time.
One of the most important ways of reducing this risk is the recording of dispensing errors and nears misses. This enables trends to be identified and improved systems to be put in place. Such an approach is encouraged by the Royal Pharmaceutical Society of Great Britain and many of the governments recent NHS reforms. However, cases such as this will only serve to discourage error reporting, thus making mistakes more likely in the future.
Clearly, a pharmacist displaying a reckless approach to their work needs to be held to account, but there are more appropriate ways to deal with poorly performing pharmacists, through professional regulation and NHS complaints procedures, both of which have been given considerably more power in recent years.
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I am a Registered Nurse. Due to a pharmacist's error I have been prevented from working in an Acute Trust where I had worked for two years. A drug was dispensed for a patient in a white cardboard box with the patients name and the drug dose clearly labelled on the box. The drug should have been checked by two pharmacists before being dispensed and sent to the ward for the patient. I administered the drug as prescribed on the drug card and on the labelled box. However, the strip of tablets inside the box were of a different strength to the prescribed dose labelled on the box. The patient was given several doses by several staff nurses before the error was detected. Whilst I should have checked the strip was the correct dose, I could not have made the mistake if the correct tablets had been dispensed. As I was working as an Agency nurse and was not employed by the Trust I was prevented from working there again. The two permanant members of staff who made the same error were not prevented from working in the Trust.I was not informed of the outcome for the pharmacists. Every error has a ripple effect and I am very angry that TWO pharmacists did not spot the error before it reached the patient who thankfully, came to no harm. One pharmacist may have a bad day....but two??? Had the patient come to harm, I dread to think what the consequencies would have been.Incompetence,when it comes to drug administration cannot be treated lightly. We have a duty to safeguard patients. There is no recommpense for the patient if the error proves fatal. Pharmacists should be prosecuted if they make errors for this very reason.
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I feel the prosecution of the pharmacist is like a backwards step but some would argue i would say that being a pharmacist. I have been qualified now for coming upto 6 years, just after i qualified we had a new contract negotiated with the department of health and one of the key points in the contract was clinical governance (risk assesment and control and minimisation). From this we were enagaged in standard operating procedures, so now just about everything we do is guided through these procedures, and part of the clinical governanace process is to record near misses and dispensing errors. (a near miss is where an error was made but was picked up and corrected before the patient recieved the medecine). These are then means to be critically appraised and looked at to see if anything can be changed or learnt to prevent the errors in the future, e.g. splitting up similar boxes. I felt strongly this was the right way forward and a means to engender a positive learning environment, and feel the most important thing about errors is the opportunity to learn and understad why the error was made. With the criminalisation of these errors these important learning opportunites maybe lost because which pharmacist is going to want to write there own prosection case?
With the change in legislation for pharmacy coming in october to the "responsible pharmacist" from the "personal control" wordings i now stand in wonder how this affects the way i should be practising. I feel very priveliged to do my job and be able to help many people get better and understand there treatments but I now fear the legislation which is coming to "help" us is maybe not what we need.
Ifeel we need honest and openness to move forward so decriminalisation would be a move in the right direction. As a first aider i was told to have my own insurance cover because of the risk of people suing you if you hurt the giving ressusitation and hurt them in the process, but were "re-assured" that it would be unlikely a criminal case would be brought. So placing these two instance in comparison both pharmacist and first aider would be doing there best for the patient either in delivering the right medication as perscribed or delivering to the best of their ability life saving aid, and both may make a mistake so the outcome is not perfect (not through negligence though)and then find themselves with a criminal prosection. In both these cases if there is no negligence on the person delivering then i feel legislation should not be criminalising the situation. But the greatest thing is as a profession we should be trying to find time to chat to customers and giving them an open view of the backgroud to pharmacy, as the legislation around it is currently being revised i feel the public should know.
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I am not a pharmacist but am a professional (Engineer).
Part of being a professional is to meet and uphold standards and also the systems and processes that ensure standards are met. Failing to meet these standards becomes a criminal offence when there is recklessness or negligence which causes harm or has the potential to cause harm. There was negligence and it did cause harm. I think that due to the reported extenuating circumstances a suspended sentance was about correct - IMO the lady did not deserve to go to jail.
From studying the reportage and reading this blog, however, it seems that pharmacists are put under undue pressure to produce quantity at the expense of those standards and the supporting processes. The role of the employer's needs further scrutiny IMO because they had a duty of care to her as an employee and to their customers. It could be argued that they have failed in this by failing to provide cover for the staff reported to be on maternity care, an I cannot imagine why they have not been pursued. The message to pharmacists is clear: WORK TO RULE. Don't skip your breaks, and if patients (or employers) complain, think to yourselves that the resulting hassle will be far less distressing than a court case. As far as I'm aware the Working Time Directive applies to pharmacists as much as it does to anyone else. Unite and make a stand.
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I no longer make mistakes. I used to make mistakes and I'd discuss them with my colleagues. They discussed their mistakes with me and we all learned something.
We're all perfect now though, which I'm sure is best for everyone.
I work within the NHS and have done for over 20 years. Now, the first question you ask yourself if something goes wrong is "does anyone else know?" If they don't, sweep it under the carpet. Simple errors destroy careers and admitting to anything untoward is professional suicide.
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In the Lee case the operator of the pharmacy was a non-pharmacist body corporate. They faced no prosecution and no professional censure from the Regulator. In a recent judgement from the European Court of Justice the ruling went in favour of the German and Italian governments who restrict the ownership of pharmacies to pharmacists alone for the protection of the public.
[Unsuitable/Broken URL removed by Moderator]
One of the reasons for the judgement was that the court considered that non-pharmacists may pressure employed pharmacists to make commercial rather than professional decisions regarding the health of their patients. The Lee case may well be an example of this. She is reported to have worked 10 hours without a proper break.
The European Commission will now have to reverse its previous position. I wonder if they will now pursue the UK government the way they pursued the Germans and Italians now they have been proved wrong?
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It's a pity that some individuals on this blog have chosen to use it as a forum for denigrating service levels in community pharmacies. If you have a problem with your local pharmacy, complain to the head office, or the PCT.
A 3 hour absence for a pharmacist (unless they are ill, or a locum has failed to attend - both very rare occurrences) would be a luxury indeed.
As for items not being in stock, then one should look at the procurement system instigated by the government for pharmacy - and the moves by manufacturers to supply directly rather than through wholesalers, and the imposition of quotas on pharmacies for items. It's becoming a logistical nightmare for us. We spend more of our time trying to get items for patients, when we should be caring for our patients.
Now back to the real point of this blog - errors.
We are all human and make mistakes. We devise systems and procedures to prevent mistakes happening, but just like slices of Swiss cheese, sometimes the holes line up, and a mistake gets through.
The best systems in the world, can't prevent human error.
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Re: comment 18
Anyone who is a healthcare professional knows that mistakes can have serious consequences and we do our best to prevent them.
Pharmacists and other pharmacy staff sometime make errors even when there is a double check (as in the incident lovelapwings describes). Nurses sometimes make mistakes when administering medicines even when there is a double check. Of course there should be systems in place to follow up these errors and reprimand when necessary. However I am sure lovelapwings would not want a nurse who had made a genuine and rare administration error prosectuted under the law.
The use of the Medicines Act in this way against this pharmacist is inappropriate and heavy handed.
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There is an interesting broader point here about the public perception of pharmacy and its role in insuring patient safety.
I would suggest that most of the time, speed is the most important factor in someone's mind when they come to collect a prescription. How many times have pharmacists heard the phrase "it's only counting out a few tablets"? But when an incident like this happens, perhaps people remember the safety aspect of the profession - not just ensuring that the correct medicine is dispensed but checking whether the prescribed item is suitable. Follow up with the prescribing doctor might be required. There is a conflict here: extra checks take time. It sometimes seems people are willing to wait longer for their Frappuccino than their medicines.
And as pillmanuk says - if you have an issue with the service in a pharmacy then there are ways to complain. Some of the practice described in other posts here sounds completely unacceptable.
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I hope that more patients and customers will contribute to this discussion because as pharmacists we need to understand their perspective, and also, perhaps, help them to an understanding of ours.
It is clear from the comments of the family in this case that they were looking for the pharmacist involved to be severely punished. This is not surprising, merely a reflection of contemporary attitudes.
But all concerned, both professionals and patients, should consider the implications and consequences that such attitudes foster. Having worked as a pharmacist in the NHS hospitals for 36 years, I have seen practice change radically in that time. When I first started work we worked individually and took personal and individual responsibility for the quality of our work. We now have to work to policies and procedures aimed at reducing dispensing errors. But I am unconvinced that the quality of the dispensing has significantly improved. The law of unintended consequences applies and the 'second checking' that is now characteristic of both pharmacy and nursing practice has, I believe, led to less personal responsibility rather than more.
Patient's expectations are also different. The time taken to dispense a prescription has inevitably increased in consequence of the procedure-driven processes we work to. But the patient only sees the end result - typically the original pack with a label attached - and is unaware of the processes involved in such an apparently simple task. Resulting irritation and interruptions only increase the stress - on one particularly difficult occasion I have asked the patient 'Do you want it now, or do you want it right?'
But perhaps the greatest source of stress for pharmacists, and no doubt other healthcare professionals, is the attitude of their managers. No procedure or policy will protect the patient if the employer, as in the case of Mrs. Lee, requires the pharmacist to work unreasonable hours without appropriate breaks and support. Yet despite many managers being pharmacists themselves, I know from personal experience that issues of stress are poorly and unsympathetically dealt with.
They, no doubt, have their own pressures but the best way to deal with issues of service quality is to ensure that the necessary number of staff are available to deliver the required workload without inappropriate amounts of overtime, breaks not taken and stress. But so long as the NHS continues to be not just a healthcare service but a tool of government policy with respect to managing inflation things are unlikely to improve.
And in case anyone should think I can't be busy if I have the time to write this, I'm taking a day off!
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I am a foreign pharmacist with 10 years experience and can probably give my view also now more as a pharmacy client. I don't dispense anymore as I work full time in another area of pharmacy, but I am disssapointed in what I see in community pharmacies when I visit them. In the past 5 years since I immigrated to the UK and have received dispensed prescription on a regular basis, I have only ONCE been councelled by a pharmacist, and most of the time I have to speak to a technician because the community pharmacist is hiding in the back! I am handed my packet and I am only asked what my address is. This is quite shocking and I think many of these dispensing errors can be avoided if pharmacisits (not the technician) talk to the patient or relative. While explaining to the patient what the medication is used for and how it should be taken, I am sure the patient will realize that they don't have the condition if there is a mistake.
I am a pharmacist, but the pharmacies I visit have no idea that I am a pharmacist. I don't need the counselling and will pick up a mistake immediately, but other patients won't know if a mistake has been made. I have an example where a doctor prescribed an anti-convulsant drug for a child and upon speaking to the father I realised that the child had only a cold. I immediately called the GP. By speaking to the father I prevented serious harm to the child and I saved the GP's career (he admitted the mistake when I called him and was grateful). We all make mistakes and are human but actually talking to patients and to each other as health professionals can help prevent many mistakes
I think that the tragic loss of life in this situation is also very much the responsibility of the employer and I do have sympathy with the pharmacist involved in this case. It is stated that this pharmacist was working under pressure and for very long hours due to two people on maternity leave. Why were these pharmacists not replaced?? I have several friends that work as community pharmacists. They work very long hours and it is very clear that the number of items dispensed is important to the employer and not the patient. It is again all about money!
Many other comments can be made about this situation. I am sure the pharmacist regrets the mistake and did not intend any harm and I am sorry that she is taking all the blame. I hope that lessons will be learned from this and that pharmacists will talk more to their patients but also that they will be supported in future and not be asked to work under extreme pressure. I also hope that the whole culture of community pharmacy wil change in the UK and that the patient actually becomes important and that it is not all about money.
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I have to agree with all of AMileInTheirShoes's comments in post 24 about post 18 - very well put!
Regarding post 20, it's important to remember that there is a difference between making an error and recklessness or negligence. Recklessness/negligence will inevitably lead to errors and should be dealt with through professional regulation and in extreme case, criminal law.
But even the most competent and careful pharmacist can make a mistake, simply as a result of only being human - everyone's picked up salt instead of sugar in the kitchen at some point, which is exactly the same type of mistake as a dispensing error. As literally millions of prescriptions are dispensed every year, it is inevitable that this will happen from time-to-time.
To prosecute someone who is competent and careful but who has made a simple error is like using a sledgehammer to crack a nut and can only result in more mistakes by discouraging error reporting.
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Post 18 Lovelapwings.
Are you proposing a different regime for nurse and pharmacists. Why should it be illegal to dispense a medicine from a registered pharmacy but not illegal for a nurse to dispense the wrong drug on a ward. We're not talking prfessional misconduct here. We're talking about prosecutions under the Medicines Act 1968. Mrs Lee received a three month suspended prison sentence and a year on probation because she pleaded guilty to a labelling offence. Research shows that on each ward in the UK nurses make up to eight drug administration errors per day. If the same logic applied to nurses as you want applied to pharmacists the number of nurses would dwindle to zero quicker than the pharmacists. Probably best to think before you speak or maybe you should turn yourself in now for your own error.
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The issue appears to revolve around errors being an inevitable consequence of long working, poor hours and terms and conditions.
Concentrating for 11 hour shifts without a break!
It seems to me that pharmacists are their own worst enemies for accepting this and the price they will pay is inevitable erosion of public confidence.
As sailor-boy-andy says no other professional groups would accept these conditions of employment, it is time for pharmacists to make a stand or accept the consequences.
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What is everybody frightened of?
It is in the public domain afer all.
It was TESCO (I'll repeat that - TESCO) that engaged Elizabeth Lee to work 10 hour shifts without a break, with a high workload and with a severe staff shortage. All conditions that will lead to errors being made.
Should she have worked to rule? Are you serious? Only if she didn't want any more bookings from Tesco.
And what have Tesco said on the matter?
To be fair all of the large chain multiples (Boots, The Co-op, Lloydspharmacy, Tesco, Sainsbury's, Morrisons, Asda, Rowlands and Superdrug) have failed to comment on this matter despite being invited to do so by the Journal of the Royal Pharmaceutical Society.
Talk about finding a scapegoat.
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Post 36 farmer_sootical
Work it out for yourself. Most community pharmacies dispense upwards of 500 items in a day. In an eight hour day that's more than 1 per minute without a break. On top of that there are methadone supervisions and needle exchange, emergency hormonal contraception consultations, medicines use reviews, diabetes checks, blood pressure checks, cholesterol checks, chlamydia screening, quit smoking advice, lifestyle advice and signposting as well as the traditional counter prescribing for minor ailments(including organised minor ailment schemes) to name but a few. The National Pharmaceutical Association (the Trade Body)and the Company Chemists Association keep accepting more and more work being piled on their employees and locums and now we're at breaking point. I'd love time to counsel every patient. 25 years ago I had the time. Unfortunatley now, in many company owned pharmacies, the time barely exists today.
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Response to gravystuffing
Surely as each new service came along there was a discussion within the pharmacy and agreement about workoad implications to ensure that they could be introduced safely?
If you need extra time, then why aren't you insisting on this to maintain professional standards?
Failure to take on these issues properly with TESCO management will leave you exposed and vulnerable to errors, just like Mrs Lee.
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Dear stuinyourownjuice
This is the way it is. The NHS through the DoH negotiate the "contract" for "services" with Pharmaceutical Services Negotiating Committee (PSNC). Thus the DoH does not recognise pharmacists in negotiations only "contractors". In the UK we have a system for Bodies Corporate to become contractors. Boots (and remember Jessie Boot was never a pharmacist) is a contractor for instance. Boots is owned by an Italian non-pharmacist billionaire and is now billeted in Switzerland. The supermarkets Asda, Tesco, Morrisons and Sainsbury are contractors. Lloyds, which is owned by a pan-European German wholesaler is a contractor. The PSNC is dominated by such non-pharmacist contractors. The DoH has no direct contact with the majority of pharmacists when it negotiates for new services. So you see ordinary pharmacists get very little say in such negotiations and indeed very little say over the control of their professional lives. In a recent judgement the European Court of Justice (Google PRESS RELEASE No 44/09 ECJ for more information) ruled in favour of German and Italian pharmacies being owned exclusively by pharmacists. It did this on the grounds of patient safety which it said overruled freedom of establishment and movement of capital. Perhaps it's about time we put the clock back in this country and gave pharmacies back to the pharmacists. I hope that puts things in to perspective for you. If you need more information please ask more questions. I'll be happy to answer them.
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I'm not a pharmacist but like most people I have to buy a prescription now and again. Recently I has a severe bout of earache and the doctor prescribed three medications - a course of antibiotics, some analgesics and some ear drops - total price £21.60.
Now what happens to someone in Scotland with a similar painful earache? they go to the pharmacy and have to pay £12... £9.60 less. And in Wales someone in the same situation as me pays nothing as prescriptions are free.
I am of course English. I pay the same taxes as a Scot or Welsh person but I am financially discriminated against for being English due to the UK's funding mechanism the Barnett Formula which values Northern Irish, Welsh and Scottish lives as worth more than English lives.
Please don't talk about pharmacies without mentioning this - it's in the public interest.
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Englandrise.....you don't buy prescriptions you pay a tax to the government. Your comment is a taxation issue and nothing to do with pharmacies or pharmacists and is completely irrelevant to this topic.
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#36 "you don't buy prescriptions you pay a tax to the government"
You must know something I don't is there a loop hole?
I distinctly heard Eddie asking for Pharmacy stories - that's my story about pharmacies. Bang on topic.
Now please tell me how I can avoid paying for prescriptions - I'm all ears.
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Response to stuinyourownjuice (posts 30 & 33):
I concur with everything gravystuffing says in post 34, but it's also worth pointing out that pharmacists, like other health care professionals, don't have the ultimate sanction of refusing to work, because then our patients suffer. When pharmacists' concerns over workload are not listened to, we could refuse to do no more than a certain amount of work in a day, but that would leave ill people without the medicines they need, something no pharmacist would ever want to see.
The profession can be its own worst enemy at times, but on this issue, our hands are tied.
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For a doctor to write a prescription incorectly for a controlled drug is a criminal offence This is an every day offence yet i have never heard of one being prosecuted for doing so.
Why do we not have a level playing field?
Blog 3 (by a doctor) refers to not receiving the quantity of medication prescribed. This is probably because pharmacists are allowed to amend quantities prescribed to the nearest calendar pack, or sub-pack, available.
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Gravystufing (why such a strange name?)in blog 34 hits the problem firmly on the head. The present set-up of pharmacy contract negotiations is being run by big business for big business. The independant pharmacy is in rapid decline due to the policy of the Pharmaceutical Sevices Negotiating Committee (PSNC) backloading remuneration in order that the stronger earn more per prescription than the weaker ( i.e. smaller, mostly independant) pharmacies.
After many years working as an independant community pharmacist I no longer dispense but work at the interfaces between community pharmacists of all sizes and types (including multiples), the Primary Care Trusts, the DH and PSNC. it is not without good reason that the Aylesbury office of PSNC is being referred to as the country home of the Company Chemists Association (the umbrella organisation which represents all the major multiple pharmacy groups).
At present a pharmacy dispensing 2179 prescription items a month (on average) earns about £24,000 less annualy than one dispensing 2180. What lunatic thought this was fair: other than PSNC which is totally dominated by the multiples and the larger players in community pharmacy.
It is only a matter of time, a short time, before the public will have little option but to patronise a pharmacy run by non-pharmacists with the bottom line (profit) seemingly more important than the safe efficient provision of pharmaceutical services.
The pharmacists working for the multiples are mostly hard-working concerned and totally professional; but the environment in which they work, the hours they must work and the pressures from Head Office to maximise profit leads to regrettable issues such as the Elizabeth Lees case. it is Tesco who should have been prosecuted not the pharmacist. a broadly similar miscarriage of justice ocured some years ago; pharmacists will recall the 'Peppermint Water case' where a major multiple should have been prosecuted not the unfortunate pre-registration student pharmacist who made the error due to inadeqaute supervision.
The ownership of pharmacies by faceless, largely foreign owned, companies is a disaster but probably, almost certainly, one that it is now too late to correct. If the public wishes to have an even better pharmaceutical service than they have now then they should frequent their independant pharmacy. They will recieve more patient focused and concerned interaction with a pharmacist who has a vested interest in their long term care than they wil at a large multiple working with a bank of pharmacists none of which is likely to have any interest other than in provision of the immediate pharmaceutical service.
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I was shocked when I read this in the pharmaceutical press. The pharmacist appeared very ethical and was just very unlucky that the judge and prosecution pushed the case. This type of case defeats the whole "fair blame" culture contained within key DoH policy documents e.g. An organisation with a memory etc., because we all make mistakes. I am a pharmacist and have made similiar mistakes e.g. dispensed a anti-diabetic medicine in place of a heart drug, but luckily the patient detected the mistake and was understanding.
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I'm a hospital pharmacist and worked in chemotherapy, end-of-life palliative care, ITU critical care, surgery, medicine and lots more. I have made and caused dispensing errors so I am a criminal, although I don't have a police record. Daily I correct doctors' prescribing errors and ommissions, and put right nurses' administration errors and help them get it right. I review medication errors and the lessons learned. The NHS must therefore be staffed by a bunch of criminals. We are humans and statistically we will, and do, make mistakes.
This situation is not in the public interest. There needs to be some old-fashioned audit in here and a review of the situation.Criminalise it where there is negligence and there are grounds to do so on grounds of natural justice.
We will go into the same staff shortages if students aspiring to professions take a negative view in the light of this situation. Shortage of paediaticians (fear litigation over child cases) shortage of social workers (what a way to treat a profession), Midwives (high litigation over childbirth accidents) Teachers(SATs)...and the rest. It's a public services syndrome.
The recession will hit funding of and recruitment to publice services. Time for some failure mode analysis and working out the wider implications of this sitaution to the public. Preferably before we are all hit by Pandemic flu and we haven't got anyone to dispense the Tamiflu correctly.
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The big chains wont think first and foremost about upholding the ethical principles of pharmacists if it gets in the way of their making profits, they'll just will want to cash in on the prestige that having a pharmacy brings to support their wider "stack'em high, sell'em cheap" business interests.
They have already denuded communities through the country of their local butcher, baker, grocery and fishmonger and deprived these communities of the care and personal service that they used to receive from the owner proprietor of these businesses. Its pharmacy's turn now.
Lets face it, having a pharmacy is not core business to a company like Tesco who will take 100 times more from their grocery isles. It would be nice to hear from Sir Terrence Leahy on the subject though, but I fear not, as his long term share bonus of £12M is linked to the perfomance of "Fresh and Easy" convenience stores in the US, (mind you a "fresh and easy pharmacy" has a certain ring to it eh Terry?)
If the pharmacy profession is in the hands of profiteers and carpet baggers, God help it! as they've got the ethical principles of a polecat in a chicken house.
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Re post 40. At 08:38am on 03 Jun 2009, pharmacist64 wrote:
Gravystufing (why such a strange name?)
For more from Gravystuffing check out LocumVoice.
For a clue to the name, check out the petition.
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Re. Post 40 "The ownership of pharmacies by faceless, largely foreign owned, companies is a disaster but probably, almost certainly, one that it is now too late to correct."
To see why one day things might change check out the European Court of Justice judgement of May 19th 2009. The Commission vs the States of Germany and Italy. To reference this Google PRESS RELEASE No 44/09.
Also watch out for my letter in the PJ soon tying together the Lee Case, the ECJ Judgement and the Responsible Pharmacist regs.
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As a Pharmacist it would be lovely if all 'scripts could be checked by three qualified and experienced people but until the NHS funds pharmacy properly it just isn't going to happen .All Pharmacies are cutting staff not increasing them and although 'self checking' is meant to only happen in occasional circumstances it does occur more frequently. we are supposed to create a 'mental break' and then return to each item but that all takes time . when you have six patients all impatiently waiting for their items and complaining that's its been ten minutes for 'only tablets' you are under pressure. and asking the teenage Saturday girl to check you is not the answer . more pharmacists would be great but who is going to pay for them ? As for breaks , well, if you leave the area the premises has to close, so employers do not pay you, so you stay. When agreeing to a long shift I make sure I have a sit down at least but on returning you have to catch up with the 'waiters' , more stress than not having a break ?
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Weldricks Pharmacy were disappointed to read the comments made by dcellist on the 1st of June.
We are committed to providing a high standard of customer care and would be very concerned if our staff behaviour and service delivery are as described on the blog.
We have 55 Pharmacies,several adjacent to supermarkets, and so can not identify the branch concerned.
We would encourage dcellist to complain either via our website www.weldricks.co.uk or to pick up a practice leaflet from one of our Pharmacies, which explains our complaints procedure. In this way we can investigate the issues raised and respond appropriately.Please use the following reference HIW55 on any correspondence, to enable us to correlate the complaint to the blog comments.
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I trained as a pharmacist but stopped working in a dispensary environment as soon as I had completed my pre-registration
year. The pressures I had seen on individuals was unacceptable to me.
This is an extract of an email I had sent to a colleague discussing this situation.
Criminlisation, I don't quite understand why everybody is so shocked at the pathetic response of the society, I expected it as an eventuality due to lack of strong professional representation. It is an error, I think of a root cause analysis was done, they would find that the company this lady worked for had set up a framework of policies which is inconsistent with the day to day service delivery that their own business targets demand; SOPs to satisfiy RPSGB standards, business model to maximise profitability. The two are interlinked funding issues for the pharmacy contract holders, I do not think many community pharmacies meet these, number of staff required for certain prescriptions etc.
Having discussed these issues many a time before with a number of pharmacists and contract holders, it is a common problem that counter staff with no formal training are accounted for as dispensing staff to meet the criteria set out by the society, a widely acknowledged problem, thus resulting in shortage of staff in the dispensary and pressure mounts on the pharmacist in charge. There are many contributory factors like these which business men see as maximising profit exercises without acknowledging the increased risk to the public. I find it amazing that the professional body that is responsible for governing these contractors does not ackowledge such mischievous conduct. Perhaps updated guidance and a responsible contractor programme needs to be provided to them.
Ultimately, every pharmacist knows where they stand legally when they make a dispensing error, if it is made within the context of SOP guidelines, the superintendant pays the price, questions need to be raised about the accountabilty of these people. Are they writing SOPs as get out clauses which are not consistent with their very own business targets and ambitions for dispensing turnover, or as truly applicable procedures which serve to protect public and also the pharmacist. I believe there has been a recent case whereby a judge acknowledged such devious behaviour, although it was relating to another profession, can't remember now.
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It is very sad that the error made by the pharmacist Mrs.Lee happened,and one of the most important points to make,I feel,is that errors are going to become more and more common because of the increasing volume of prescription items dealt with in retail chemist outlets(community pharmacists).
This issue,the extreme stress put upon community pharmacies,needs to be addressed.
I've worked as a pharmacist in community for about twelve years,and if you want to see an account of how a pharmacist has a mental breakdown in a pharmacy,do visit the website of the National Perceptions Forum www.perceptionsforum.org.uk where I have a piece under my name "Andrew Low" called "An Incident in the Dispensary".
I was very interested to hear the one listener,a doctor I think,felt one should cover up errors,sweep them under the carpet,but I do not agree with this.This is why things like the Dr.Harold Shipman murders took place.Sure,we do not need to broadcast errors more than necessary,but it's wrong,although possibly easier in some cases,to hide them.
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I've just listened to the interview. One of the people in it mentioned in passing the responsibility of of the drug manufacturers in this whole situation, though this wasn't followed up. Any discussion of this issue must involve these companies and an exploration of some of the competing interests around patented and generic drugs, in particular.
I emailed the programme last week with details of another mixup that is currently happening between two very different formulations of the same drug. Mixing them up can have very serious consequences involving possible rejection of a transplanted organ. The packaging is very similar - leading my mother to be taking the wrong one for over 40 days before spotting the error. In her case the mistake was in the less serious direction. Do get in touch if this slipped through the net.
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I agree with cebunster. The provision of NHS pharmacy services is underfunded and has been for a very long time. While dispensing errors should not be a criminal offence, they do obviously need to be eliminated as far as is humanly possible. Checking systems are in place at most of the pharmacies where I work as a locum pharmacist, but in none of them is there adequate staff provision to carry them out all of the time. In addition, we are being asked by the government to carry out more and more tasks and to shoulder more responsibilities, including private consultations with patients to carry out medication use reviews, selling medicines which were previously restricted to prescription such as the morning after pill and, soon, to perform vascular risk checks. All this on top of taking the reponsibility for every prescription which leaves the pharmacy, even when it has been dispensed by someone else or if there has been a prescribing error by the doctor. A higher level of staffing is required and a higher price put on the cost of dispensing each prescription.
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The bulk of these errors seem to comment about community errors.
Have you ever considered the number that go unreported or get covered up in hospital!
What about all the off licence or unlicensed medication that goes out without proper paperwork being completed.
MHRA changed sterile talc from a device to an unlicensed product a trust i know of issued it out 50 times before it was brought to their attention, is this not a error.
What about all the risk assessments that the NPSA want pharmacists to carry out and implement, one of them being the changing practice of how oral chemotherapy is screened, presribed to protocol to avoid dosing errors. I know of some that have occured and nearly killed people because the July 2008 deadline for this to have been implemented has not been done by certain cancer networks. Surely this shows that the prescription has not been screened for clinical appropriatness, possibly because there was no protocol to check it against. Maybe the patients are not issued with a complete set of written information which leads to these types of errors. Should we be blamming the NPSA for issuing alerts but not following them up across all trusts?
The whole thing is a mess and the society need to start doing more checks in NHS hospitals and private hospitals, not leaving it to the SHA to check boxes when they do their once in a life time visit!
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Looking at all these posts I do wonder what I have started!
The examples I gave to Jennifer were of errors I had made whilst working in an NHS hospital. We chose my first one for the interview. The point I was keen to get across in my discussions with her was that the workload for pharmacists across both community and hospital was increasing in amount and complexity and that the support was not always there in every situation to accommodate this.
With regards to Pharmacist420 - I now work in a private hospital which is not registered with the RPSGB so they have no right of inspection. We are however inspected regularly by the CQC and these are always thorough. We are compliant with the NPSA Patient Safety Alerts and Rapid Responses - this was checked at the last CQC inspection. We're all aware that some Trusts and Independent Sector Providers aren't but there is no transparency in reporting this nationally. We also have to report compliance internally and to the PCT - I feel that I am far more closely and critically scrutinised in my practice now than I ever was in the Trust.
The pharmacy teams I have worked with in community and hospital have always been very open in discussing errors within the workplace and looking to change practice or process to reduce the risk of a repeat error. We cannot, as a profession, allow the Lee judgement to stop us doing this and learning from each other although the potential consequences of being open and co-operative are now very clear. The RPSGB have joined in the campaign to decriminalise isolated dispensing errors. We now need them to represent our interests effectively in a very practical way and push other parties (employers, manufacturers and others) to look at the actions they can take to design errors out of the system by improving working conditions, staffing, workload, systems and products.
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51. At 4:27pm on 09 Jun 2009, fretter1 wrote:
I agree with cebunster. The provision of NHS pharmacy services is underfunded and has been for a very long time.
I don't entirely agree with this. Underfunded it may be but a proportion of the funding goes to provide dividend for non-pharmacist owners and shareholders. If pharmacists owned their own pharmacies then that money would be kept within the business. The recent European Court of Justice judgement points out the dangers of this and supports the German and Italian (amongst others) view that only pharmacists should own pharmacies. The European Commission will have to change its view on this. Perhaps the DoH should follow suit.
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I've just read through most of the comments on this blog with interest. I am not a pharmacist but I am suppose I could be classed as a little biased by some people as I am married to one.
Until I met my husband like many I wandered how much a pharmacist actually has to do. Now I understand much better having heard him talk about the fun of contacting doctors when they have made a mistake on a script, supervising methadone, medicine user reviews and many of the other extended services talked about in the comments here. He doesn't get a lunch break - if he is lucky he gets 10 mins to go grab a sandwich which he eats over several hours. And that depends on him having two members of staff. Mucvh of the time it is him and one other - indeed at times I have been known to go sit in the back of the pharmacy so it can stay open due to staffing issues. Luckily I work in a job where I can do some stuff when not in work (in fact a lot). Plus there are the times we have done delveries on our way home.
My husband has been at times under severe pressure from his managers over his lack of providing things like MURs, as this is one funding route. As for pharmacists working to rule - all the ones I know put the care of the patient first. Many memmebrs of the public complain bitterly when they ahve to wait more than a couple of minutes for their medications - indeed I know most 'multiples' put an expected waiting time of 10 mins or less if the drugs are in stock.
My husband says much as he would sometimes prefer to work as an independent it just doesn't pay. The bigh 'multiples' have the purchasing power and the clout to get things done their way - and the pharmacist you meet (if you are lucky and he/she is not too busy) has little say in what the contract with the NHS says.
As to the funding - the government has squeezed the money for pharmacies - and indeed rules mean that if (like my husband's pharmacy last month) went a few items into the next band for practice payments but didn't have the corresponding increase in dispensing staff hours then you lose the payment - in his case it was about 20 items which meant his staffing hours should have been 56 not 40 - the banding is arbitary and slight montly variations like this can lose a pharmacy a lot of money. No wonder many independent pharmacists now struggle to survive...
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I am a pharmacist in Hampshire and have been working over 2 and a half years on a series of projects. Our profession is undergoing a lot of changes in the way we practice and we are undoubtedly doing a lot more. Our projects focus on a range of initiatives to navigate through these periods of change without putting our patients at risk. We are rising to the challenges of the new contract and issues like this dispensing error just demoralises a lot of our colleagues.
I wrote an article in April 2009, which I have decided to publish on our website entitle: Pharmacy: The Compassionate Profession ( http://www.bookapharmacist.com/?page_id=516). It details a range of issues I am wrestling with as a pharmacist in the frontline of NHS practice and issues we are wrestling with collectively as a profession.
We are not calling for a change in legislation because we think dispensing errors are irrelevant. As a profession, we impose upon ourselves high standards and we frown on any of our colleagues who does not maintain such high standards. Mistake are inevitable, even with all the wills in the world. We want an environment where we can practice safely and learn lessons from any dispensing mistakes and errors.
Kazeem Olalekan MRPharmS
MUR Evangelist
Project Lead
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I wanted to go into pharmacy but after reading all of these horror stories i decided against it and went for a more lax career. I just don't know if i could take the pressure so I don't regret it a single bit. I went into mechanical engineering instead and wouldn't go back for a million dollars. i would definitely be making more as a pharmacist but money certainly isn't everything in this case! great blog thanks for posting it.
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